International Journal of Nursing Sciences 4 (2017) 266e270

H O S T E D BY Contents lists available at ScienceDirect

International Journal of Nursing Sciences

journal homepage: http://www.elsevier.com/journals/international-journal-of-
nursing-sciences/2352-0132

Original Article

The effect of health literacy level on health outcomes in patients with

diabetes at a type v health centre in Western Jamaica
Sherryon Gordon Singh*, Joyette Aiken
The University of the West Indies, Mona - Western Jamaica Campus, 10 Queens Drive, White Sands P.O. Montego Bay, St. James, Jamaica

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To identify the effects of health literacy levels on health outcomes in patients with diabetes in
Received 24 August 2016 a type V health center in Western Jamaica.
Received in revised form Method: A correlational survey design with a random sampling technique was used. An 18-item ques-
30 January 2017
tionnaire and the Newest Vital Sign tool were administered to 88 consenting adults with diabetes to
Accepted 16 June 2017
Available online 20 June 2017
assess their health literacy levels. Their health outcomes were evaluated with docket review. Data were
analyzed using SPSS version 18.
Results: The participants were predominantly female (77.3%), aged 51e70 years, married (44%),
Keywords:
Diabetes Mellitus
employed (46%), and diagnosed with diabetes > 10 years (42%). Only 13.6% of the study population was
Health literacy adequately health literate. The health literacy scores for gender were not signicant (P 0.84). The
Health outcome health literacy scores of the patients with different ages and educational levels were signicant
(P < 0.001). Pearson's correlations revealed no linear relationship between health literacy scores and
health outcome (r 0.185, P 0.084).
Conclusion: Limited health literacy and high likelihood of limited health literacy are predominant in the
study population. Age and educational level are signicantly associated with health literacy levels.
However, these ndings suggest no association between health literacy level and diabetic health
outcomes.
2017 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction patients with diabetes experience an overwhelming responsibility

Noncommunicable diseases (NCDs), such as heart disease,
stroke, cancer, chronic respiratory diseases, and diabetes, are the
leading causes of mortality worldwide. Among these conditions,
diabetes is the fourth leading cause of death and is accounted for
1.5 million deaths annually [1]. Diabetes is an increasing health
problem internationally and locally, and its projected prevalence
and nancial burden on healthcare services have increased. In Ja-
maica, diabetes is the second leading cause of death [2] and is
diagnosed in 7.9% of the population [3]. This condition is also costly
because of its chronic nature and the severity of its complications,
thereby affecting not only the patients with diabetes and their
families but also the Jamaican economy and healthcare system.
Health literacy should be promoted because a complex thera-
peutic regimen is necessary to manage or control diabetes, but
* Corresponding author.
E-mail address: sherryon.gordon@uwimona.edu.jm (S. Gordon Singh).
Peer review under responsibility of Chinese Nursing Association.
of navigating healthcare systems and making appropriate health
choices. Health literacy is dened as cognitive and social skills that
determine the motivation and ability of individuals to gain access,
understand, and use information in a manner that promotes and
maintains good health [4]. Health care has undergone changes as a
result of modernization and globalization, and healthcare envi-
ronments have become increasingly complex. With a high health
literacy level, the patients' access to health information and their
aptitude to use it effectively are improved, and these patients
consequently feel empowered.
The ability to access healthcare systems, engage in self-care, and
manage chronic diseases is inuenced by an individual's health
literacy level [5]. The lack of understanding of health information
compromises an individual's ability to make informed health de-
cisions and thus negatively affects their health outcomes. Health
outcome refers to the consequences of healthcare actions among
patients and the possible results of the presence or absence of in-
terventions [6]. Limited health literacy has been linked to adverse
health outcomes, including decreased use of preventive health
services, poor disease-specic outcomes for certain chronic

http://dx.doi.org/10.1016/j.ijnss.2017.06.004
2352-0132/ 2017 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 S. Gordon Singh, J. Aiken / International Journal of Nursing Sciences 4 (2017) 266e270
conditions, and increased risk of hospitalization and mortality [5].
The health literacy level of patients also serves as a guide for
healthcare providers on how to communicate with patients effec-
tively. However, health literacy and its relation to diabetes and
outcomes for diabetic patients in Jamaica have yet to be investi-
gated. Therefore, this study aims to determine the relationship
between health literacy levels and health outcomes for patients
with diabetes in a type V health center in Western Jamaica. Our
ndings will provide a basis for the planning and implementation of
strategies by healthcare providers to improve the health outcomes
of patients in Western Jamaica because relevant information should
be considered in the development of education and health policies.
2. Methods
2.1. Participants and setting
A single-site study was conducted in a type V health center at a
medical clinic. The type V health center serves a population of
50,000 and provides the following services: prenatal care, postnatal
care, family planning, immunization, laboratory services, family
counseling, nutrition counseling, child guidance, home visiting,
HIV/STI counseling, testing and treatment, and curative services.
The target population consisted of patients diagnosed with dia-
betes by a healthcare provider (medical doctor/nurse practitioner)
and with a fasting plasma glucose of 7.0 mmol/L (126 mg/dl) or
2 h plasma glucose 11.1 mmol/L (200 mg/dl). The included pa-
tients visited the medical clinic at least three times between
January 2015 and the time of data collection.
2.2. Inclusion criteria
The following inclusion criteria were considered: male/female;
age 18 years and diagnosed with diabetes by a healthcare pro-
vider (medical doctor/nurse practitioner); fasting plasma
glucose  7.0 mmol/L (126 mg/dl) or 2 h plasma glucose
11.1 mmol/L (200 mg/dl); at least three random/fasting blood
glucose readings recorded in a patient's docket since January 2015;
and ability to speak, read, and write.
2.3. Exclusion criteria
The following exclusion criteria were considered: age <18 years;
patients diagnosed with gestational diabetes; less than three
random/fasting blood glucose readings from January 2015 to the
time of data collection; and evident or documented cognitive de-
fects because cognitive problems may interfere with accurate
health literacy measurement [7].
2.4. Sample size
An average of 144 individuals diagnosed with diabetes visited
the type V health center per quarter in 2015 [8], and the calculated
sample size for our study was 105. The required sample size was
estimated using the Creative Research System (2012) and the Sur-
vey System Correction (2012) for nite formula. Of the calculated
105 sample size the research yielded a total of 88 participants in the
study (83.8% response rate) as 17 forms were incomplete.
2.5. Procedure
An 18-item questionnaire consisting of demographic, knowl-
edge, and practice of diabetes management questions was self-
administered, and the Newest Vital Sign (NVS) tool was given to
the participants who satised the inclusion criteria. The NVS is an
267
objective, valid, and reliable screening tool that provides a realistic
context that patients can understand. It is also a quick and easy-
open access sourced tool that facilitates health literacy level mea-
surement. This tool yields good internal consistency with Cron-
bach's a of 0.76, and its criterion validity was r 0.59 and P < 0.001.
The correlation score between the NVS and the Test of Functional
Health Literacy in Adults (TOFHLA), which is a widely used tool to
measure health literacy levels, was 0.88 [9].
The content and face validity of the 18-item questionnaire were
assessed and reviewed by two content experts. This questionnaire
consisted of demographic questions and other questions that
evaluate an individual's knowledge and practice of diabetes
management.
The questionnaire was administered to 12 diabetic patients who
represented 10% of the proposed study for pre-testing to determine
its reliability. The questionnaire and NVS tool was administered
after a written consent was obtained. A Cronbach's a internal
consistency coefcient of <0.78 conrmed the validity of the
questionnaire. The questionnaire was slightly adjusted to improve
its esthetic appearance.
Upon the completion of the 18-item questionnaire, the partici-
pants were given nutritional labels retained throughout the
administration of the NVS referring to the label as often as desired.
Six questions on the NVS tool were asked by the researchers on the
basis of the nutrition label. Upon completion of the tool, the results
were scored immediately after the participants were shown
appreciation for participating in the study.
A docket review was conducted to note the last three random
blood glucose readings of the participants. The blood glucose
readings were averaged and then rated as controlled (2 h blood
glucose <11.1 mmol/L/200 mg/dl) or uncontrolled (2 h blood
glucose >11.1 mmol/L/200 mg/dl) based on the WHO criteria and
was recorded on a data extraction sheet. The absence or presence of
acute and chronic diabetic complications was also noted. The acute
complications of diabetes include diabetic ketoacidosis, hypergly-
cemic, hyperosmolar, nonketotic syndrome, and hypoglycemia.
Chronic complications are long-term disorders of the microcircu-
lation and are classied as one of the following three types: mac-
rovascular (coronary artery disease, cerebrovascular disease,
hypertension, and peripheral vascular disease), microvascular
(retinopathy and nephropathy), and neuropathic (sensorimotor
and autonomic dysfunction) [10]. This procedure was performed
between January 2015 and the date of the interview and was
recorded on the data extraction sheet. Data were collected at the
site by the researcher over a 10-week period between April and
June 2016.
2.6. Data analysis
Data were analyzed using the SPSS version 18. Descriptive sta-
tistics were used to summarize the data. Each demographic vari-
able was descriptively analyzed by calculating the mean (SD),
median, and mode of the age and frequency distributions. One-way
ANOVA and t-test were used to establish a relationship between
health literacy levels and demographical factors (age, gender, and
educational level). Cross tabulations using Pearson Chi-Square
correlation were also utilized to show the relationship between
health literacy level and health outcome. Health outcome was
determined on the basis of the presence or absence of the acute/
chronic complications of diabetes and random blood glucose levels.
A health outcome score was developed on the basis of the pre-
ceding variables. Each variable was scored as follows: presence of
acute diabetic complication (1); absence of acute diabetic compli-
cation (0); presence of chronic diabetic complication (1); absence of
chronic diabetic complication (0); uncontrolled random blood
268 S. Gordon Singh, J. Aiken / International Journal of Nursing Sciences 4 (2017) 266e270

glucose level (1); and controlled random blood glucose level (0). 2.7. Ethical consideration
The variables were rated, scored, and totaled. The cumulative
scores of 2e3, 1, and 0 indicated poor health outcome, fair health Ethical approval was received from the ethics committee of the
outcome, and good health outcome, respectively. P  0.05 was University Hospital of the West Indies, the University of the West
considered signicant for all inferential statistic tests. Indies, the Faculty of Medical Sciences of the University of the West
Indies, and the Ministry of Health. Ethical approval was also
received from The Western Regional Health Authority Ethics
Table 1 Committee for conducting the pre-test and the research.
Demographic characteristics of the participants (N 88). Informed consent was obtained from each participant. All of the
Variables N (%)
participants were assured of anonymity and condentiality and
were informed of the purpose, the procedures, risk, benets, and
Gender
voluntary participation. This information was reinforced with an
Male 20 (22.7)
Female 68 (77.3) information letter outlining the study and an informed consent
Age (years) form signed by each participant.
18-30 0 (0) No personal identifying information was included on the tool or
31-50 17 (19.3)
report to ensure condentiality, and each participant was randomly
51-70 54 (61.4)
>70 17 (19.3)
assigned a study identication number. All efforts were made to
Mean Age group-51e70, SD 0.625 provide anonymity, and the participants were informed that the
Marital Status patients' involvement would not affect their care at the clinic.
Married 39 (44.3)
Divorced 2 (2.3)
Widowed 12 (13.6)
3. Results
Separated 2 (2.3)
Single 33 (37.5) 3.1. Demographic characteristics
Employment Status
Employed 40 (45.5)
The participants were predominantly female (77.3%), and the
Unemployed 20 (22.7)
Retired 28 (31.8) majority was diagnosed with diabetes >10 years (42%). Most of the
Educational level patients were 51e70 years old (SD 0.625), and the age groups
None 0 (0) 31e50 years and >70 years were evenly represented (19.3% each).
Primary 16 (18.2) Many of the participants were married (44.3%) and employed
All Age/Junior High 34 (38.6)
(45.5%). Of the 88 participants, 34 (majority) completed junior high
Secondary 28 (31.8) school and 2 nished college/university (Table 1).
Technical/Vocational 8 (9.1)
College/University 2 (2.3)
Years diagnosed with Diabetes 3.2. Health literacy level
<1 11 (12.5)
2-5 26 (29.5) Of the total participants, 59.1% possibly had limited health lit-
6- 9 14 (15.9) eracy, 27.3% were highly likely to have limited health literacy, and
>10 37 (42.0)
13.6% showed adequate health literacy (see Fig. 1).

Fig. 1. Distribution (%) of the levels of Health Literacy (HL) in diabetics at the Type V Health center.
 S. Gordon Singh, J. Aiken / International Journal of Nursing Sciences 4 (2017) 266e270 269

Table 2
Relationship between Health Literacy levels and demographic factors (age, gender, educational level).

Demographic Factors Health literacy Levels Standard P value

Deviation
Suggested high likelihood Possibility of limited Adequate health
of limited Health literacy (n) health literacy(n) literacy(n)

Age (years) <0.001

31e50 1 9 9 0.606
51e70 13 36 5 0.563
>70 10 7 3 0.507

Gender 0.084
Male 10 7 3 0.745
Female 14 45 9 0.581
Educational level <0.001
Primary 6 10 0 0.500
All Age/Junior High 14 19 1 0.551
Secondary 0 20 8 0.460
Technical/Vocational 4 2 2 0.886
College/University 0 1 1 0.707

3.3. Relationship between health literacy levels and demographic
factors (age, gender, and educational level)
Health literacy scores were signicantly related to age and
educational level (P  0.05 or P < 0.001). Health literacy scores and
gender were not signicant (P 0.84; Table 2).
3.4. Correlation of health literacy score and health outcomes score
Pearson's correlations revealed no linear relationship between
health literacy scores and health outcomes (r 0.185, P 0.084).
3.5. Comparison of health literacy levels, blood glucose level, and
presence of acute/chronic diabetic complications
More than half of the participants (n 39) who possibly had
limited health literacy (n 26) and with a high likelihood to have
limited health literacy (n 13) had controlled blood glucose levels.
The majority of the participants (n 40) who possibly had limited
health literacy (n 16) and were highly likely to have limited
health literacy (n 24) had no acute diabetic complications and no
chronic diabetic complications (n 71). Pearson's correlation
(Table 3) indicated that health literacy level was not related to the
control of random blood glucose (r 0.031, P 0.771), acute
complications (r 0.260, P 0.376), and chronic complications
(r 0.054, P 0.620).
4. Discussion
Health literacy was a challenge among the participants. Bourne
et al. [11] assessed the health literacy and health-seeking behaviors
of Jamaican males aged >55 years and identied that majority of
the participants (48.2%) have health literacy deciency. Diabetic
patients with challenges in health literacy experience a long-term
health conict in obtaining, understanding, and applying health
information to enhance their self-management capabilities. Our
ndings emphasized the need for healthcare providers to identify
low health-literate diabetic patients and facilitate adjustments in
health communication methods and thus improve the outcome of
the required self-management.
Health literacy scores were signicantly related to age and
completed educational level (P < 0.001). This nding is signicant
in Jamaica, where seniors are accounted for the high prevalence
rates of NCDs [12]. This result is consistent with other ndings
related to age and health literacy. Ashida et al. [13] evaluated the
levels of genetic knowledge, health literacy, and beliefs about the
causation of health conditions among individuals in different age
groups. They found that the health literacy levels of older in-
dividuals are lower than those of younger individuals (P < 0.001).
The decreased physical and mental health and an increased risk of
cognitive decline with age can affect a patient's ability to obtain,
understand, and apply health information; these observations are
consistent with low health literacy among older adults across var-
ied populations [14].
Our study showed that a high educational level corresponds to a
high health literacy level and vice versa. This nding is also
consistent with the 2012 International Assessment of Adult Com-
petencies, in which a high percentage of adults whose educational
levels are below the high school level achieve lower health literacy
levels than adults with high levels of education do [15]. Hence, the
educational attainment of individuals is important. Baker [16] also
stated that educational attainment contributes to the development
of individual capacity, which is necessary to deal effectively with
health information, healthcare personnel, and health care system.
Our ndings indicated a gender imbalance with a male:female
ratio of 20:68. This ratio at almost 1:3 is slightly higher than the

Table 3
Cross tabulation of health literacy levels, blood glucose level and the presence of acute/chronic diabetic complications.

Health Literacy Level Blood Glucose level (n) Acute DM Complication Chronic DM complication
present(n) present(n)

Controlled Uncontrolled Yes No Yes No

Suggested high likelihood of 13 11 8 16 0 24

limited health literacy
Possibility of limited Health Literacy 26 26 28 24 5 47
Adequate Health Literacy 6 6 9 3 0 12
Pearson's Correlation 0.031 0.260 0.054
P Value 0 0.771 0.376 0.620
270 S. Gordon Singh, J. Aiken / International Journal of Nursing Sciences 4 (2017) 266e270
national prevalence rate in Jamaica, where 3.2% and 6.3% are dia-
betic males and females, respectively [12]. The relationship be-
tween health literacy scores and gender was not signicant
(P 0.84) in this research. International views on gender and
health literacy levels have been inconsistent. The International
Assessment of Adult Competencies (2012) reported high health
literacy in females, but other studies have shown no difference in
health literacy levels between genders [17].
Pearson's correlation revealed no relationship between health
literacy scores and health outcome score (r 0.185, P 0.084). This
research did not consider the social, cultural, and religious practices
of the participants and did not utilize an intervention-based
method, and these limitations could affect the results. These nd-
ings suggested no relationship between health literacy level and
health outcome, but other studies have yielded inconsistent results.
Al Sayah, Majumdar, Williams, Robertson, and Johnson [18] sys-
tematically reviewed health literacy levels and health outcomes,
including knowledge, behavioral, and clinical outcomes, of diabetic
patients. In their review, 24 included studies revealed that the
relationship between health literacy and clinical outcomes is
inconsistent. They also reviewed 13 studies (12 cross-sectional and
1 longitudinal studies) to identify the relationship between health
literacy and glycemic control. Studies adjusted for age, gender, race,
education, and treatment regimen have reported that high levels of
health literacy were associated with good glycemic control. Other
studies have indicated that health literacy is not directly associated
with glycemic control. The systematic review found that two
studies addressed health literacy and self-reported hypoglycemia.
One of these studies suggested that low health literacy is related to
the high occurrence of hypoglycemia, but the quality of evidence
from the studies is low. Two studies have demonstrated health
literacy level and self-reported diabetic complications. One study
showed no evidence of the association between health literacy and
self-reported complications. The other study identied an associ-
ation among low health literacy, retinopathy, and stroke.
Our research provided valuable information but exhibited some
limitations. Our results could not be used for generalization
because of the relatively small sample size with predominantly
female participants and the single site nature of the study. Our
research was also not based on intervention. As such, the true as-
sociation between health literacy and diabetic health outcomes
could not be determined.
5. Conclusion
The study indicates that the possibly limited health literacy and
the high likelihood of limited health literacy are predominant in the
diabetic population in the type V health center in Western Jamaica.
Moreover, demographic factors, such as age and educational level,
are signicantly associated with health literacy levels (P < 0.001).
Our ndings emphasized that healthcare providers must identify
low health-literate diabetic patients, consider the challenges of the
aging population and the undereducated, and adjust health
communication methods to improve self-management by diabetic
patients. Therefore, healthcare providers must be trained to
determine and communicate with individuals of limited health
literacy levels.
No relationship was identied between health literacy and
health outcome. However, future longitudinal intervention-based
studies would be benecial to describe the association of health
literacy and outcome in detail. As partners in health care, health-
care providers should be equipped with the knowledge, practice,
and beliefs regarding health literacy, and these characteristics must
be evaluated to facilitate the development of optimal health pro-
motional activities for diabetic patients.
Funding
This research did not receive any specic grant from funding
agencies in the public, commercial, or non-prot sectors.
Author contribution
Gordon Singh conceived and designed the study. Aiken super-
vised the entire study. Gordon Singh collected, analyzed and
interpreted the data. Gordon Singh drafted the manuscript. Aiken
was involved in manuscript revision. Gordon Singh takes re-
sponsibility for the paper as a whole.
References
[1] World Health Organization. WHO j diabetes: world health Organization 2014.
2014. Available from: http://www.who.int/healthpromotion/conferences/
7gchp/track2/en.
[2] Registrar General's Department. 2003. Available from: http://www.rgd.gov.
jm.
[3] Wilks R, Younger N, Tolloch-Reid M, Mcfarlane S, Francis D. Jamaica health
and lifestyle survey 2007-8. Kingston: University of the West Indies; 2008.
[4] World Health Organization. 2009. Available from WHO Track2: Health literacy
and health behaviour: http://www.who.int/healthpromotion/conferences/
7gchp/track2/en.
[5] U.S. Department of health and human. Quick guide to health literacy services.
2011. Retrieved from: http://www.health.gov/communication/literacy/
quickguide/factsbasic.html.
[6] Kaufman S, Spertus J. About my health outcomes. 2011. Retrieved from:
Myhealthoutcomes:http://www.myhealthoutcomes.com/faqs/3005.
[7] Baker D, Williams M, Parker R, Gazmararian J, Nurss J. Development of a brief
test to measure functional health literacy. Patient Educ Couns 1999;38(1):
33e42.
[8] Montego Bay Type V Medical Records Department. Number of diabetics on
diabetic register. (S Gordon Singh, Interviewer). 2016.
[9] Weiss B, May M, Martz W, Castro K, Dewalt D, Pignone M, et al. Quick
assessment of literacy in primary care: the newest vital sign. Ann Fam Med
2005;3(6):514e22.
[10] Smeltzer S, Bare B, Hinkle J, Cheever K. Brunner & Suddarth's textbook of
medical- surgical nursing. twelfth ed. Philadelphia: Lippincott Williams &
Wilkins; 2010. p. 1201e41.
[11] Bourne P, Morris C, Charles C, Eldemire -Shearer D, Kerr-Campbell M,
Crawford T. Health literacy and health seeking behavior among older men in a
middle-income nation. J Patient Relat Outcome Meas 2010:39e49.
[12] The World Bank. Non-communicable diseases in Jamaica: moving from pre-
scription to prevention. 2010. Available from: http://www.siteresources.
worldbank.org/INTLAC/Resources/NCDsJamaica.pdf.
[13] Ashida S, Goodman M, Pandya C, Koehly L, Lachance C, Stafford J, et al. Age
differences in genetic knowledge, health literacy and causal beliefs for health
conditions. Public Health Genomics 2011;14(4e5):307e16.
[14] Simon MA, Li Y, Dong XQ. Levels of health literacy in a community-dwelling
population of Chinese older adults. Journals Gerontology 2014;2(Suppl 2):
54e60.
[15] Center for Disease Control. Health literacy for public health professionals.
Available from: http:www.cdc.gov/healthliteracy/training/page669.html.
[16] Baker D. The meaning and measure of health literacy. J General Intern Med
2006;21(8):878e83.
[17] Hughes H, Bowers M, Mckee V, Saladino L, Sawyers T, Washington D, et al.
Comparison of health literacy by race and gender among heart patients. Cir-
culation 2014;130. A20349eA20349.
[18] Al Sayah F,Majumdar SR, Williams B, Robertson S, Johnson JA. Health literacy
and health outcomes in diabetes: a systematic review. J General Intern Med
2013;28(3):444e52.